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Topical Acne Therapies: Optimizing Patient Adherence

R. B. Vender, MD, FRCPC, FAAD
Dermatrials Research, Hamilton, ON, Canada

Background

Topical acne formulations are the most common treatments used by patients and prescribed by family physicians and dermatologists. Patients feel more comfortable using topical therapies because they have milder side-effects, can be easier to use, are generally less expensive, and are more readily available.

The vast spectrum of topical acne treatments allow for an individualized approach that can be tailored to meet the needs of each patient. However, even with a wellconceived treatment plan, when the patient leaves the office with the prescription, appropriate steps must be taken before the patient actually uses the medication as intended. Patient adherence is crucial in preventing treatment failure.

Causes of Nonadherence

Two primary reasons directly influence nonadherence1:

1. Difficulties encountered with the patient-physician relationship

  • Patients misunderstand the clinicianís instructions.
  • The treatment strategy selected is not explained sufficiently.
  • The realistic expected rate of improvement and potential treatment outcomes are not effectively conveyed to patients.
  • Emphasize that the goal is for management and not to cure their acne.

2. Treatment-related issues

  • Patients misunderstand the side-effects of treatment.
  • Patients misinterpret the risks and benefits of treatment.
  • Treatment regimen and instructions are too difficult to follow.
  • Patients forget to apply the medication.
  • Patients find that the therapy is intolerable.
  • Patients find that the cost of therapy is prohibitive.
  • Patients have difficulties storing the medication properly.
  • The medication has an unpleasant odor.
  • The vehicle is inappropriate.

Improving Adherence

Developing a rapport with acne patients is a crucial component in realizing treatment success.2 If a comfortable ongoing dialogue can be established, patients will tend to offer a more thorough account of their treatment experiences and feel more compelled to adhere to prescribed therapies.

Tips to Improve Adherence

  • Gain the trust of your patients by being receptive to their individual needs through eliciting their input and expressing empathy surrounding their unique circumstances.
  • Consider organizing a dedicated acne counseling session that is guided by experienced nurses.
  • Express concern by following-up with patients who have missed appointments.
  • Provide handouts that reinforce the aims of the selected therapies, explain the facts about acne and treatment expectations; such literature can serve as at-home reference material.
  • Educate patients about the prevalence of acne and reassure them that they are not alone.
  • Address nonadherent issues with the patient.
  • If the patient is dissatisfied with the current treatment, be willing to modify the therapeutic approach.
  • To improve short-term adherence, it may be necessary to increase the frequency of clinic visits.
  • Long-term adherence can usually be achieved once short-term adherence has been established, which usually occurs when patients notice improvement in the signs and symptoms of their acne.
  • Recommend the use of gentle non-soap cleansers to avoid compounding irritation and dryness from medication.
  • Flexibility for application, i.e., switching morning and night use depending on tolerance, once daily, or prn use.
  • Encourage patients to keep checklists and diaries in order to monitor adherence.
  • Different topical antibiotics, benzoyl peroxide (BPO), and retinoids may be combined for less frequent usage.
  • Adjust the frequency and duration of application to reduce side-effects; increase dosage as tolerated.

Adolescent Patients

  • Consider seeing teenaged patients alone, without parents, to explore any sensitive issues that they may be more comfortable expressing one-to-one.
  • Be aware that teenaged patients may be especially vulnerable to heightened anxiety about their appearance.
  • Encourage patientsí suggestions of medications that friends may have recommended.
  • If a parent is present, make sure to address the teenaged patient and not the parent.
  • Greet the patient first and then the parent or guardian.
  • Offer after school appointments to avoid disrupting their curriculum.

Tips for an Effective Office Visit

  • Avoid making the patient feel rushed through the visit.
  • Allow adequate time for patients to discuss their concerns and provide feedback about the prescribed treatment.
  • Suggest that all acne medication and skin care products be brought to each visit for pharmaceutical editing.
  • Minimize waiting room time for patients to reduce frustration.

Considerations for Vehicle Selection

When deciding on suitable treatment options, a thorough assessment of individual needs in terms of acne severity, lifestyle, and preference of delivery vehicle must all be jointly considered.

  • Patients with drier skin may prefer creams for their moisturizing properties.
  • Patients with oilier complexions may prefer the lighter feel of gels, lotions, solutions, or foams.
  • Less viscous formulations, such as lotions, gels and foams are better suited for application on larger surface areas and regions with greater hair density.
  • Minimize irritation by using aqueous vehicles rather than those containing alcohol when possible.
  • Product innovations, such as the new pump delivery system that is used for the BPO/ clindamycin combination make application easier and may promote patient adherence.
    • Compounded by the pharmacist for optimal efficacy and low irritation.
    • Results may be visible as early as 2 weeks.
    • Fewer ingredients may lessen the potential for irritation.

Considerations for Treatment Selection

Improved adherence may be achieved by considering the features of anti-acne therapy. Accessibility of the anatomical site for topical therapy, i.e., the face, chest, and shoulders are more accessible than the back. Other important considerations include: efficacy, tolerability, cosmetic acceptability, regimen simplicity, convenience, and ease of application.

Drug Type Topical Acne Agents Overview
Antibiotics
  • BPO
  • Clindamycin
  • Erythromycin
  • Sodium sulfacetamide
  • Directed against P. acnes.
  • Formulated in creams, ointments, lotions, gels, foam.
  • One product is also available with SPF 15 + antibiotic.
  • May induce irritation and dryness.
Combination products3
  • BPO + antibiotic
  • Topical retinoid + antibiotic
  • Both are gel formulations that treat multiple pathogenic factors.
  • Combined efficacy is typically greater than either agent alone.
  • Reduction in regimen complexity may improve adherence because there are two active ingredients.
  • Combined use of a topical antibiotic with BPO can reduce the emergence of bacterial resistance.
Retinoids
  • Adapalene
  • Tazarotene
  • Tretinoin
  • Vehicle delivery advancements reduce irritation and enhance efficacy4:
    • formulated as an emollient cream and microsponge gel.
  • Known to be effective against acne vulgaris through comedolysis, which acts to reduce dyskeratosis at the pilosebaceous outlet.
  • They are formulated as gels, creams, and solutions, which may
  • induce irritation and dryness.
Table 1: The spectrum of topical acne medications5

Suggestions for Prescribing

  • Assessment and diagnosis of the patientís acne as inflammatory or noninflammatory narrows the treatment prospects.
  • Limit the use of BPO on the chest and back due to its bleaching effect on clothing; recommend nighttime application and suggest wearing old t-shirts or sleepwear.
  • It is important to educate patients about the expected side-effects of all prescription and over the counter products that they are currently using.
  • Consider alcohol-based solutions for the chest and back.
  • Consider a cotton ball application for topical medications that include dabber applicators.
  • Ensure the patient has an adequate supply of medications, i.e., large quantities for larger areas.
  • Prescribe multiple tubes or jars of medications for use at different locations, e.g., school, lockers, gym, home.
  • As much as possible, use simplified regimens.
  • Provide estimates of amounts to apply by using descriptive references that are easily understood by the patient (e.g., apply a pea-size amount of gel to each of the five facial regions: forehead, each cheek, chin, and central face).
  • Missed applications and nonadherence to the prescribed regimen are often unreported to the treating physicians; bearing this in mind, the dosage may need to be increased.
  • Patients should be assessed every 2-3 months to monitor therapeutic efficacy.

Conclusion

Adopting a comprehensive approach that takes into account individual preferences, properties of available treatments, and disease severity can encourage patient adherence and lead to improved treatment outcomes. However, often underestimated, but representing the key to gaining adherence, is the attention devoted by physicians to establishing effective communication with the patient through:

  • patient education on acne and the aims of initial and maintenance treatment.
  • patient engagement in treatment selection.
  • counseling on aggravating factors, medication use, adverse events, and the importance of adherence.

References

  1. Renzi C, et al. Arch Dermatol 138(3):337-42 (2002 Mar).
  2. Baldwin HE. Dermatol Ther 19(4):224-36 (2006 Jul-Aug).
  3. Del Rosso JQ. Cutis 78 (2 Suppl 1):5-12 (2006 Aug).
  4. Date AA, et al. Skin Pharmacol Physiol 19(1):2-16 (2006).
  5. Tan J. Skin Therapy Lett FP 3(4):4-5 (2007 Nov).